Will Insurance Cover My Breast Reduction?
in New York City & Manhattan

*Model

by Dr. Steven Wallach

Breast reduction surgery, or reduction mammoplasty, is a procedure that many individuals consider for both physical and emotional relief. Whether it’s due to chronic back, neck, or shoulder pain, difficulty with physical activity, or self-esteem issues, having large breasts can negatively impact quality of life. But one major question often arises for those contemplating the surgery: Will my insurance cover it?

The answer is not always straightforward. Unlike some cosmetic procedures that are typically out-of-pocket, breast reduction can sometimes be deemed medically necessary, which opens the door to insurance coverage. However, the process for approval can be complex and requires meeting certain criteria set by your health insurance provider.

In this blog, we’ll explore the factors that influence insurance coverage for breast reduction surgery, what documentation you might need, and tips to increase your chances of getting approved.

When Breast Reduction Is Considered Medically Necessary

Health insurance companies may cover breast reduction if it is deemed medically necessary rather than purely cosmetic. So what qualifies it as a medical need?

You may have a strong case if you are experiencing:

• Chronic pain in your shoulders, neck, and upper or lower back
• Nerve pain or numbness caused by bra straps digging into your shoulders
• Skin rashes or infections under the breast folds
• Posture problems
• Difficulty engaging in physical activities or exercising
• Psychological distress, including body image issues or low self-esteem

To determine whether your symptoms meet the threshold for medical necessity, your insurance provider will typically evaluate a combination of clinical documentation and photographic evidence. Additionally, they may require that you have attempted non-surgical treatments like physical therapy, chiropractic care, or weight loss programs.

Insurance Requirements: What You’ll Likely Need

Although each insurance provider has slightly different requirements, here are the most common criteria and documents needed for coverage:

1. Letter of Medical Necessity

This letter is usually written by your primary care physician, gynecologist, or plastic surgeon. It should clearly explain:

• Your medical symptoms
• Treatments you’ve tried
• How those treatments failed
• Why breast reduction is the recommended next step

2. Documentation of Physical Symptoms

This may include:

• Medical records of doctor visits regarding your back, neck, or shoulder pain
• Physical therapy reports
• Chiropractor or orthopedic notes
• Prescription records for pain medications

3. Photos

Some insurance companies require photos to assess the degree of breast hypertrophy (enlargement) and any visible signs of physical impact like indentations from bra straps or rashes.

4. Weight of Tissue to Be Removed

Many insurance providers have a minimum tissue removal requirement, often guided by the Schnur Scale, a chart that estimates whether the amount of tissue being removed is proportional to the patient’s body surface area. If the proposed reduction meets or exceeds the threshold, it’s more likely to be considered medically necessary.

Pre-authorization and Appeals

Most insurance plans require pre-authorization before you can proceed with surgery. Your plastic surgeon’s office often assists with this process by submitting the necessary documents and forms to your insurance.

If your initial request is denied, don’t give up. Insurance denials can often be appealed successfully, especially if additional documentation can be provided. Your surgeon’s office may help you with the appeals process by submitting more comprehensive records or clarifying how the surgery addresses medical issues.

Plans That Are More Likely to Cover the Surgery

While each insurance plan is unique, some of the major providers known to cover medically necessary breast reductions include:

• Blue Cross Blue Shield
• Aetna
• UnitedHealthcare
• Cigna

It’s crucial to read your specific plan’s medical policy or speak directly with a representative. Be sure to ask:

• What specific documentation is required?
• Are there any weight or BMI requirements?
• Is a referral from a primary care provider necessary?
• Does the surgeon need to be in-network?

Final Tips for Navigating the Process

1. Do your homework. Contact your insurance company early and ask specific questions.
2. Choose a board-certified plastic surgeon experienced in breast reduction procedures and insurance submissions.
3. Gather thorough documentation from multiple healthcare providers to support your case.
4. Stay persistent. Don’t be discouraged if the first request is denied—appeals are often successful.

Conclusion

While the road to getting insurance coverage for breast reduction surgery can be filled with red tape and paperwork, it’s entirely possible—especially when your symptoms have a documented impact on your health. By understanding the criteria, preparing comprehensive documentation, and working with an experienced surgeon, you can significantly improve your chances of getting the surgery covered.

If you’re considering breast reduction, schedule a consultation with a qualified plastic surgeon and start the conversation with your insurance provider. Relief from chronic pain, increased mobility, and improved confidence could be well within reach.